Appendix B Verification/Endorsement Form for Administrator Licensure
To be used by candidates completing the Administrative Apprenticeship/Internship
Part I. To be completed by the applicant (print)
Name:
MEPID:
Street Address:
City/Town:
State:
Zip:
License Field and Level Sought:
Field Experience Site Location:
Site Location District: Westport Community Schools
Grade Levels of Site:
Beginning Date of Field Experience:
End Date of Field Experience:
Part II. To be completed by the trained Mentor
(print)
Mentor Name:
Mentor Title:
Mentor License #:
Part III. Completion of Field Experiences (signatures of candidate and trained mentor required)
Verification of candidate completion of required minimum field experience working with the trained
mentor and engaged in professional activities that address the Professional Standards for Administrative
Leadership.
Please select one administrator role:
Special Education Administrator (500 hours)
School Business Administrator (300 hours)
Candidate Signature:
Date:
Mentor Signature:
Date:
Part IV. Licensure Endorsement Statement (signature of superintendent required on this document for
candidates completing an Administrative Apprenticeship or Internship)
I verify to the Massachusetts Department of Elementary and Secondary Education that the above
named candidate for the above named administrator license has successfully demonstrated application
of the Professional Standards for Administrative Leadership detailed in 603 CMR 7.10 through an
administrative apprenticeship/internship with the trained mentor listed above, in accordance with
Department Guidelines.
Superintendent Signature:
Date:
Superintendent Name (print): Dr. Ann Marie Dargon
License #:
Guidelines for Administrator Routes to Licensure Page 1
Part V. Performance Assessment (Please see Appendix E of these Guidelines)
Please Note: Principal/Assistant Principal candidates seeking licensure through any licensure path will
be required to participate in the Field Trial of the PAL beginning in September 2014. Additional
guidance re: the Field Trial will be posted to the following on the Department website:
http://www.doe.mass.edu/edleadership/pal/.
Beginning in Fall 2015, the Performance Assessment for Leaders (PAL) will be required for earning a
Principal/Assistant Principal license.
The candidate must also complete a performance assessment that demonstrates successful application
of the Professional Standards for Administrative Leadership to be eligible for licensure as an
administrator. Please complete the Performance Assessment for Licensure Verification Form.
Supporting documents must be maintained by the candidate and the district for a period of five years.
Performance Assessment for Initial Licensure Verification Form
Part I. To be completed by candidate
Professional Standards for Administrative
Leadership (603 CMR 7.10)
Evidence
Standard I. Instructional Leadership:
Standard 2. Management and Operations:
Standard 3. Family and Community
Engagement:
Standard 4. Professional Culture:
Guidelines for Administrator Routes to Licensure Page 2
Part II. To be completed by the trained mentor
Standard
Rating
Standard 1 Instructional Leadership
Standard 2 Management and Operations
Standard 3 Family and Community Engagement
Standard 4 Professional Culture
Rating Scale: 1=Does Not Meet the Standard; 2=Meets the Standard, 3=Exceeds the Standard; NA=Not Applicable.
Summary Assessment of Performance:
Administrator candidate’s Performance Assessment for Initial Licensure in the administrative
apprenticeship/internship meets the Professional Standards for Administrative Leadership:
Yes No
Trained Mentor (sign):
Date:
Superintendent (sign):
Date:
Guidelines for Administrator Routes to Licensure Page 3
Appendix C Candidate Checklist
The following checklist is provided to assist a candidate in completing the application process
and assembling the documents required by the Department:
Pass the Communication and Literacy Skills MTEL (the testing company electronically submits
scores to the Department).
Complete the licensure requirements for the administrator role sought through one of the
available routes.
Apply for licensure and make payment using the online process
(www.doe.mass/edu/educators).
Submit one of the following:
o
Approved Program Endorsement
o
Administrative Apprenticeship/Internship Verification form
Submit a letter written on official letterhead by the superintendent/designee,
principal, or previous employer that documents the candidate has completed three
years employment in the role of the license sought or other required experience.
Administrative Apprenticeship/Internship candidates only: Submit Performance
Assessment for Initial Licensure Verification Form.
Submit official transcripts of undergraduate/graduate studies if required for specific
license.
Submit evidence of SEI Administrator or Teacher endorsement (if applicable).
All supporting documents should be submitted to the:
MA Department of Elementary and Secondary Education
Licensure Office
75 Pleasant Street
Malden, MA 02148
Guidelines for Administrator Routes to Licensure Page 4
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